I’m trying not to make my commentary about the current Ebola outbreak about representation, but I’ve been a bit troubled by the political analyses accompanying the epidemiological and health systems ones. Specifically, I want to talk a bit about how Liberia’s and Sierra Leone’s civil wars have been deployed by these analysts to understand the response to the outbreak and how explaining existing tensions requires some deeper knowledge about local context.

Laurie Garrett’s recent opinion piece on CNN and her appearance on Melissa Harris-Perry’s show are both examples of this kind of minimally informed political analysis. There is nothing unique about her stance, I suppose. We see this sort of “war changes everything” or “war happened, therefore…” logic quite a bit. But because she is such a well-respected journalist — I loved The Coming Plague in college and became interested in public health because of that book — I think it’s worth discussing here. As much as I have admired her work, I am beginning to see how her analysis, combined with a reputation for producing compelling journalistic accounts of global health problems, may successfully reproduce the tropes that make for interesting and juicy news, but may not help the cause.

One reason it is useful to understand the context is that even reading newspaper editorials requires some knowledge of existing tensions and conflicts. Yesterday, Garrett tweeted a link to an Awareness Times editorial, focusing (in her short Twitter allotment) on the ignorance of a “very important citizen” who underestimated the threat of the disease publicly. While this may very well be one of the points the editorial was making, I think Garrett’s tweet might be missing the point. It helps to know that the Awareness Times is a paper through which Sylvia Blyden, who has been very vocal and critical of the government response to Ebola from very early on, is communicating her disapproval of the government response to the epidemic.

It is also helpful to know that she has ruffled some feathers on many political matters. According to another Facebook friend, Blyden traveled to the Canada some months ago to collect donations for protective gear to help stop Ebola from spreading. Sylvia Blyden’s critique of this “very important citizen,” therefore, must be understood as a critique of the official response to the disease and elites’ repeated claims that rural people are uneducated and ignorant when it comes to assessing their risk for disease. Rather than simply demonstrating ‘ignorance’ of an elite class, then, she is also criticizing complacency and inadequacy of official response. She is disparaging their assessment of rural people.

In her CNN opinion piece, Garrett reminds of us all the backlash against health workers within these Ebola affected communities. She recounts the story of the woman with Ebola whose family removed her from the hospital and was “brought to a traditional healer.” “Brought to a traditional healer” is usually code for ‘culture’ and ‘tradition’, which tend to be, well, euphemisms for ‘backwardness.’ But any medical anthropologist or most undergraduates who have taken an introductory medical anthropology course, for that matter, knows and understands that an individual’s therapeutic itinerary is often related to perceived efficacy. Put more simply, folks’ quest to get better often means looking in multiple places for cures. In the case where biomedicine can’t get the job done, or you’re seeing people enter hospitals and not coming out, where would you go?

Certainly these protracted conflicts have done their damage, but it has been noted that some of the causes of the war were, indeed, the perceived failures of the state and the mistrust engendered in the late 1970s and early 1980s. These were tales told to me by older politically involved individuals whom I encountered during fieldwork in the mid-2000s. One friend, an anthropologist currently in Liberia and who lived in Sierra Leone before and during the war, described how people use the war to explain current problems, when she had observed the same misfortune and problems those years before the war. She wrote, “I remember driving along the Kamakwie road with someone who was saying what a shame the war had destroyed the road. I said, actually, this is pretty much exactly what the road was like before the war too.”

I am sure that if you asked any anthropologist who happened to work in Sierra Leone in the 1980s about changes, they would see little change on some issues, but radical changes in others. Because time has passed. Moreover, war does not affect everyone the same. During one of my first interviews for preliminary dissertation research in 2005, I remember a cousin of a friend telling me, “We were very comfortable during the war. We stayed in a nice little place on the outskirts of Freetown and were very safe.” Her story wasn’t exactly typical, but it was not unusual either for a specific class of individuals. If anything, we might ask how intervention has been naturalized under these narratives about ‘failed’ and ‘fragile’ states, as my friend Susan Shepler has said. It also appears to naturalize the outbreak and responses to it: “well, they’ve experienced so much in war that this can only breed distrust.” The distrust and suspicion were there all along, albeit expressed in other forms. I would argue, too, that if war has changed anything, the incredible influx of humanitarian interventions and aid workers during the war and its immediate aftermath — where outsiders and their local cronies seemed to benefit openly from others’ suffering — has also engendered suspicion that has helped fuel the backlash against local and international health workers.

4 thoughts on “On the off chance that war doesn’t change everything: more on Ebola”

Hi. I’ve never replied to your posts before, and I generally enjoy your blog very much. But unfortunately, I have to say that I think that on this topic, you’re analysis is a bit off.

I’ve been doing ethnographic research in the Guinea and Liberia area since 2003, and I’ve been studying medical humanitarian intervention, coordination, and the Liberian medical system since 2005. One of the striking aspects of the coverage that I have noticed is that the political analyses have been spot-on, and the anthropologists have been getting their analyses all wrong by deferring to long-standing tropes in the discipline. Here’s a few reasons why your critiques don’t work here:

1. Traditional medicine in Liberia is, and has been, in a state of freefall as a result of the war. Due to constant population movements, the separation of adults from children, the dislocation of healers from traditional sources of herbs and medicines, and the post-conflict experience of urbanization, traditional medicine in Liberia is no longer traditional, nor is it medicine. As I demonstrate in my book Searching for Normal in the Wake of the Liberian War, the war, and the post-war social changes that followed, fundamentally disrupted the process of inter-generational education and transmission of customary healing knowledge. As a result, people who arrive at a hospital in Monrovia are as likely to die from their “traditional remedy” as they are to be killed by the failures of the medical system.

2. The war, and the post-war period, have had a fundamental impact on healthcare coverage in Liberia. In my research, I have studied the extent of the Liberian health sector as far back as the 1920’s, and indeed, there was a sharp drop off in health care expertise, health care coverage, and healthcare resources from roughly the period 1985 onwards, after Samuel Doe’s regime aggressively began to attack the Liberian intelligentsia, and the Liberian elites (including medical professionals) all fled elsewhere. In the aftermath of the war, there was very little human capital left in the country with the ability to practice medicine and medical surveillance. A network of coverage was patched together between humanitarian NGOs, with a lot of gaps in between, and the Liberian healthcare sector was jointly managed by the state and by UNMIL and the WHO. The goal was to restore full sovereignty back to the Liberian healthcare sector as quickly as possible, but what happened instead was a hot-potato hand-off from the international community to the Liberian state without sufficient infrastructure being set into place for the Liberian state to be able to accomplish effective mass surveillance, mass communication, or mass intervention.

3. At the same time the level of trust in the professional medical sector has collapsed not because of people’s attachments to traditional medicine, but because, as of 2012, well over 90% of the global pharmaceuticals in Liberian pharmacies were counterfeit, non-effective, out-of-date, or tainted in some way. As a result of the failure of the state to control its ports – one of the government arms that was rapidly and thoroughly privatized in the post-war aftermath – there is a shockingly high level of corruption, stock replacement, theft, and smuggling around the global pharmaceuticals entering the Liberian market. It’s not wonder, then, that Liberians don’t trust western medicine. When they have gone to seek medical treatment, and then ponied up the money for exorbitantly costly medications, the medicines simply don’t work.

As a medical anthropologist, I too, am critical of the media and its representation of the Liberian Ebola crisis. But on this one – the anthropologists simply have it wrong. We have to do better.

Thanks for your response. Perhaps you should write this on your own blog because the points are well-taken and are specific to Liberia, which I don’t actually address.

Also, the Laurie Garrett argument is one that I think doesn’t actually cover much of what you write here. She just didn’t know much about the context, more generally, in her attempts to bring attention to this critical issue.

Also, I don’t disagree with much of what you have written here. I’m not sure you’re contradicting anything that I’ve said. I find that people go to many places when they feel like the medicine at the hospital is also failing — and when people are dying more than they are being cured. This is the nature of Ebola and not simply a function of therapeutic itineraries/traditional medicine/whatever. No cure/no treatment is a tough thing to deal with.